Many of the myths and challenges in private duty nursing (PDN) may be due to the lack of knowledge of what PDN truly is. There are many misconceptions about PDN regarding lower pay, lack of opportunity for career advancement, a less diverse nursing experience, the cost of benefits, and the thought that a PDN nurse may not be challenged enough in their role. These myths are not based on reality and should be debunked because such misconceptions contribute to the challenges some PDN companies are experiencing in onboarding nurses to work with the pediatric medically complex population at home. As medical care becomes more complex in PDN, it is imperative to provide families with an expert team of nurses (Larsson et al., 2022). The primary challenge of the pediatric home health care crisis is to develop a well-trained and adequately compensated workforce to meet the needs of children and their families (Foster et al., 2019).

A recurring concern for the State of Delaware is whether the current private duty nursing workforce is sufficient to care for all resident children with medically complex needs. In 2020, a study was completed with a sample of current PDN nurses, family caregivers, agency providers, and nurses not affiliated with PDN to determine the capacity of the home health nursing workforce to serve our current medically complex pediatric population in the State of Delaware (University of Delaware et al., 2021). Within the data from this study, many nurse participants believed PDN was “less challenging, less stimulating,” or believed working in PDN would not “advance their career” (University of Delaware et al., 2021). There are also challenges related to a shortage of private duty nurses to care for clients in need, and a lack of specialized education nurses need to provide safe, high-quality care to the current medically complex pediatric population.

How do we address the thought process of current nursing students as well as promote PDN positions to the experienced nurse to make sure our medically complex children, not only in Delaware but all over the world, are cared for safely? Currently, BAYADA Pediatrics office has approximately 83 clients in Delaware who require PDN in their homes, and among them, there are many open shifts due to the lack of available nurses. A national survey of family caregivers of children with complex medical needs reported that 52 percent of family members had to reduce their work hours, 42 percent took a leave of absence, 31 percent turned down a promotion, and 21 percent gave up working or retired early to meet the care needs of their children (Foster et al., 2019). This may cause physical, financial, and mental stressors for the families. Not only does this affect the families, but also the availability of beds within our hospitals. According to a study in Minnesota, out of 185 children who required home nursing, 57 percent of hospital discharge delays were directly attributable to a lack of access to home health care, which, in turn, accounted for 1,454 unnecessary hospital days (Foster et al., 2019).

To change these situations, organizations need to develop a plan. PDN agencies can start to develop relationships with our local universities. Currently, BAYADA Pediatrics in Delaware has developed three contracts with local universities to allow nursing students to use our organization as a clinical site. As students participate in clinical hours in the field or office, they will be able to experience the tasks and skills required to become a PDN nurse caring for medically complex children. This may encourage more nursing students to choose PDN as a career. Other options may be to add PDN content to an existing class in all nursing programs covering job flexibility, benefits, the importance of the nurse in a client’s home, and professional development opportunities when working with PDN organizations. One nurse response from the referenced study stated, “I imagine that much of the PDN is not necessarily of the ‘skilled’ variety. I imagine being expected to also do housekeeping types of tasks rather than those that require nursing skills” (University of Delaware et al., 2021). This statement couldn’t be further from the truth. Clients and their families are in desperate need of highly skilled nurses to ensure the safety of children who require multiple pieces of medical equipment, such as those with a tracheostomy, a ventilator, a central line with medication infusions, or an insulin pump for managing diabetes. A typical day may involve packing up all the emergency equipment needed for a trach/vent client to attend school and riding the school bus. This equipment usually includes a ventilator, suction machine, oxygen, emergency airway bag, nebulizer machine, and feeding pump. A PDN nurse may need to monitor a child with a seizure disorder or assist a diabetic client with entering information into their insulin pump, as well as monitor them throughout the school day to be sure they do not develop hypo or hyperglycemia. They may need to provide regular respiratory treatment or emergent interventions or administer IV medications through a central line. There are so many opportunities to learn, practice, and advance diverse and essential nursing skills in PDN.

It is estimated that over one million more nurses will be needed by the year 2030 to care for projected populations (Kiger et al., 2023). One solution to attract and retain competent PDN nurses may be to provide them with an opportunity to complete a nurse residency program (NRP). According to the Institute of Medicine, 35 to 60 percent of new nurses leave their first job within one year. However, one-year retention rates range from 86 to 97.2 percent for those nurses who completed a nurse residency program (Linscheid & Bell, 2021). Newly licensed nurses in the US report feeling overwhelmed and unprepared when entering the nursing workforce (Kiger et al., 2023). BAYADA currently offers a yearlong Nurse Residency Program that starts with four to six weeks of specialized education using clinical simulation labs, online, interactive sessions, and hands-on experience to prepare the novice nurse with the confidence, skills, and clinical expertise needed to provide safe, high-quality care for our pediatric medically complex population at home. To work in the PDN field, new nurses and those experienced in other care settings must learn and practice the skill set and critical thinking skills to provide home care autonomously. These nurses have to be able to make sometimes critical next-step decisions regarding the care they are providing. In the PDN field, there are no code blue buttons, respiratory therapists, or physicians at the bedside. PDN nurses make decisions that will keep their clients safe and stable. PDN nurses tend to have a broader skill set than that of a nurse working in a hospital setting because they do not have the same resources immediately available in an emergency. If we provide PDN nurses with the education and training needed to care for such complex clients, our communities will likely exhibit fewer hospital stays, fewer emergency room visits, a better quality of life, and more stability remaining in their own environment with the beneficial support of loved ones.

PDN should not be viewed as a drain on state budgets but as a tool to prevent hospitalizations, control health care costs, and support the gainful employment of family caregivers. Accessible, high-quality home health care has the potential to improve health outcomes in both the client and the family-centered fashion (Foster et al., 2019). Several studies have highlighted that PDN nurses fill a critical role in the care continuum. PDN nurses act as a link between the patient, physicians, therapists, equipment companies, and more. They play a crucial role in the coordination of care on behalf of the patients and their families.

Medically complex children deserve the care we would expect for our own family members, but in order to provide that care, we need to make both the novice and expert nurses more aware of what a day in the life of a PDN looks like and that does not include “housekeeping.” Private duty nurses experience fulfilling work, ample opportunities for career advancement, and a sense of true contribution and collaboration with their teams. For more information about PDN or to ask questions about this article, please contact Taryn Pariag, MSN, RN, a clinical educator for BAYADA Home Health Care, at tpariag@bayada.com.

References

Foster, C., Agrawal, R., & Davis, M. (2019). Home health care for children with medical complexity: Workforce gaps, policy, and future directions. Health Affairs, 38(6), 987–993. https://doi.org/10.1377/hlthaff.2018.05531

Kiger, C., Draucker, C., & Otte, J. (2023). The attributes and influence of individuals associated with newly licensed registered nurses in nurse residency programs. Journal for Nurses in Professional Development, 39(3), 143–149.

Larsson, R., Erlingsdóttir, G., Persson, J., & Rydenfält, C. (2022). Teamwork in home care nursing: A scoping literature review. Health & Social Care in the Community, 30(6). https://doi.org/10.1111/hsc.13910

Linscheid, N., & Bell, D. (2021). The journey of a home care nurse residency program. Home Healthcare Now, 39(2), 99–106. https://doi.org/10.1097/nhh.0000000000000949

University of Delaware, Culnane, M., & Giancola, S. (2021). Private duty nursing workforce capacity study (Publication T21-025.-56) [Research study]. University of Delaware.